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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ► (Complete in Triplicate) !' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insapplicab°n is tall the work herein described.This made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for weil/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ot D 1. F \a ' City Lot Size Owner's Name r � �• Address PhoneISN ��+- ,¢�, � Z License No. X(16 G 7fgPhone Contractor ddress ,` "�� " y� ► TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L7- SYSTEM REPAIR ❑ OTHER C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LIN FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDER USE -R TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,� ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -� Dia. of Well Casing Type of Casing— El ! Specifications ❑ DomesticlPrivate Ll Gravel Pack L1 Tracy g _Y ❑ Public ❑ Other 17 Delta Depth of Grout Seal,' " Type of Grout -� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by— ' y r` "' 'ice ^ ► q Repair Work Done '❑ Type of Pump_ H.P. State Work Done_.. Well Destruction [IWell Diameter; Sealing Materia top 50'1 t Depth I+ Filler Mats ial{Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I( REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nonseptic system permitted.if public,sewer is available within 200 feet.)!- ti r Instaltation will serve: . Residence Co @ ial Other Number of living units: __— Number of bedrooms Character of soil to a depth of 3 feet Water table depth _ / } `SEPTIC TANK C�T a/Mfg Capacity Y�a No. Compartments t r " Method of Disposal PKG. TREATMENT PLT,.@ ! f Distance to nearest: Well L,� _ Fo ndation(� Property Line --......._ t 0 O LEACHING LINE D. No. &Length of lines Total length/size + D — FILTER BED U Distance to nearest: Well 8 Foundation � ra f- Property Line f - r SEEPAGE PITS ❑ Depth i Size Number SUMPS G Distance to nearest: Well Foundation Property Line DISPOSAL PONDS? 11 L1 I r 1 hereby certify that l Have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. Horne owner or licensed agent's signature certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall not ng or sub employ any person in such manner as to become subject to workman's com -contracting signature pensation laws of California.-d,IshllContractor'sns subjecttoo workman's compensa- " certifies the following:''l certify that In the performance of the work for which this permit-is issued,I shall employ per I tion laws of California.. T The applicant. I!f r all required pactiom. Complete drawing onre side. Signed ` { Title: _ Date: — 14ZEPARTMENT USE ONLY p d '; (� u. 0 ,n, _kn,-� , Date `_ 1 1- Area Application Accepted y k _ Final Inspection by {n Dat Pit or Grout Inspection by Date f Additional Comments:�'�^� ^-y `^— �"'^ .. u,.<�y C Stk 466-6781 C3 Lodi 368-36'11 ❑ Manteca b3-7104 G Tracy 835-6 385 Applicant- Return all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUET AMOUNT REMITTED O SH RECEIVED HY DATE PERMIT^NO. INFO + EH 13-24(REV.i/epi t �V-V C) JrJL..� EH 1420 1